Experiential Psychopathology - Dr John Howells

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V- A Salutiferous Society

The third approach to experiential family therapy calls for consideration of the concept of a salutiferous, health-promoting society (1).
In the long term this is the most effective help to society, the family and the individual.

The family is the basic organism in society. As a constituent of society it contributes to society. Equally, society contributes to it. Each family relates to all the other families that make up the psychic environment outside itself; it can equally suffer. The more health-promoting, salutiferous, is society, the more will its families benefit.

Thus it is essential to examine society for its health-promoting potential. Should the functioning be inveterate, set and permanent, this would be a wasteful exercise. Its malignant permanence would have to be accepted. Fortunately, society, like the family and the individuals, is endowed with the capacity to change.  Its infinite pattern of functioning can be restyled; herein is society’s capacity for health. In the final hierarchy of phenomena, the pneumococucus is as significant as a person. In some circumstances, it might even have greater importance than a person. In our set of circumstances, the pattern has to be moulded against the pneumococcus and in favour of man. Man has the capacity to develop awareness to the point when he can, within the limits allowed him, reshape the pattern of functioning to his advantage. Hitherto, his predominant endeavour has been concentrated on adjusting his material environment. With this task largely accomplished in developed countries, there should now be resources to re-pattern the psychic sphere of living.

The author sees society as a vast field of forces in which elements are loosely defined – culture, community, neighbourhood, family, individual; essentially each element has equal significance. The emotional forces within the life space produce degrees of well-being or harm and they can be re-patterned to promote either. Understanding of this potential for change in either direction allows the conscious selection of patterns of emotional forces toward bringing well-being to society and to the elements within it. Thus, through generations, a reshaping of the emotional self-improvement.

Much thought and print has been expended in attempting to define health. It is easier to feel it than to define it. Its correlates are easy to delimit and describe – emotional and physical well-being, the capacity to adjust to life’s stresses, the ability to co-operate with others, unselfish actions born of security, efficiency, and productivity. All these indicate harmonious functioning in the individual – what he feels is the comfortable state of “being well”.

Most definitions of health are in terms of the individual; it may be more realistic to attempt it in terms of society, which ultimately dictates the state of its elements, families and individuals within it. It might be thought that society is sick only in the sense that it contains a number of sick people. It is more correct to say that society itself is sick and therefore must contain a number of sick individuals. At the moment, forces within society are arranged in a pattern that provokes emotional ill-health, which flows from one generation to the next. Society carries within it the capacity for health because its fields of force carry the potential for rearrangement. This fact makes clinical endeavour worth while. Health and “normal” behaviour of course must not be confused. The normal, usual, statistically average state of emotional functioning in society is far from “health”. With each succeeding generation it is hoped that the emotional norm will increasingly approximate to health – a state of affairs being achieved slowly and with difficulty in the field of physical health.

The clinician’s endeavour is the production of health. In family psychiatry the goal is a healthy family, with, of course, healthy individuals, a task always limited by the fact that social ill-health pulls the family towards conformity to its norms. Over the generations, small gains in the rearrangement of the vectors will have a cumulative effect on society. Gains can be made at individual, family and social levels, and the process is indivisible. For the present, the family is the vantage point. Progress can be made only at the speed with which knowledge develops. But clinical effort carries the prospect of new insight; research and clinical work go hand in hand.

It is one of the central themes of this writing that discernment must come before change, diagnosis before therapy. So it is with an effort to make society health-promoting, or salutiferous. It is necessary to know what is required for healthy human functioning – bit it individual, familial or social. The lessons of health often emerge from a study of ill-health. Thus, the first step is a massive assessment of dysfunctioning in society. It can operate at three levels: (i) what accounts for the dysfunctioning in society as an organism (where do its harmful leaders, movements, collective aggressive acts, etc, spring from); (ii) what accounts for the contribution of society to the dysfunctioning of the family (what harmful values, habits, restrictions, etc does it impose on the family); and (iii) what accounts for the involvement of society in the dysfunctioning of the individual (what harmful psychic noci-vectors spring from its institutions – schools, industry, neighbourhoods, etc).

Central to any evaluation is to establish standards. Paradoxically, standards of health often emerge only after an examination of ill-health. The absence of ill-health is easier to ascertain than the presence of health. Over time, sometimes as the result of trial and error, the pattern of optimum functioning for a salutiferous society will emerge. A further complication is added by the fact that what is optimum functioning at one moment in history is not optimum functioning at another. Fortunately, change takes place in collective human functioning at such a slow rate that this is unlikely to be a serious complication. It might be supposed that change in society takes place very rapidly today. But this would only be true of material change; the level of general psychic well-being in the most materially developed of societies is often not only very low, but lower than in materially poorly endowed societies.

It may be useful to contrast briefly what is being said about the creation of a salutiferous society with what is termed “social psychiatry”. This latter has been the subject of much confusion, especially concerning such aspects as “therapeutic communities”, “therapeutic milieu”, “community psychiatry”, etc. The first two are concerned with the climate of psychiatric institutions, a humanising movement that allows of more patient involvement, greater freedom, and a constructive group feeling; they are a reaction to the rigid institutionalisation of the last two hundred years, and only partly ameliorated, here and there, by the efforts of Pinel, Chiarugi, Conolly, and Tuke in the 19th century. Community psychiatry has affinity with social psychiatry and the terms are often used synonymously. It is a movement that wishes society to take a larger share of the care of the mentally ill, who, according to it, should remain in the community. Thus, it emphasises the need for day hospitals, hostels, etc, to keep patients in the community rather than in hospitals and the need for “after care” agencies to facilitate their discharge from hospitals. All the above are elements, but only a few, within a health-promoting society, a salutiferous society. The salutiferous society is concerned not only with the management of the identified ill, but much more with identifying influences that encourage dysfunctioning, and then re-patterning social living so that the level of emotional, and not “mental”, functioning improves. It has to do not only with the management of the alcoholic, for instance, but with all the adverse practices in society that set up the particular combination of psychic noci-vectors that precipitate alcoholism.

The salutiferous society has affinity with the preventive movement in the physical field that has made such a significant contribution to the improvement in the standard of physical health. It is more useful to talk of the promotion of health, than the prevention of ill-health. It is easier to persuade a person to win a race than persuade him not to lose it. Hence, health promotion and the term “salutiferous”. The salutiferous society could be said to embrace both psychic and physical health; here it will be employed as it relates to the former. Indeed the two are indivisible, as change for the better in one encourages an improvement in the other. In preventive organic medicine there has been a systematic analysis of those elements in life which are antagonistic to physical health. The tubercle bacillus was isolated, it was shown to have a bovine form, the bovine form was transferred by the milk of affected cows to children and hence bovine tuberculosis that was responsible for such deformities in children in the past. The understanding of this process led to large-scale preventive procedures largely by promoting the health of cows. (As in physical medicine, so in psychic medicine, the understanding of pathology is the key to health promotion.) It will be noticed that curative and health-promoting medicine go hand in hand. Clinical work led ultimately to the isolation of the tubercle bacillus; preventive measures then took over. Curative medicine is both a palliative and a research endeavour. Similarly, there is no contradiction between curative and preventive psychic medicine. They complement each other. Psychic medicine has its palliative and research functions and leads to large-scale health promotion efforts.

Satisfaction of material needs to a large degree, together with the recognition of emotional phenomena, makes it now within our grasp to enter this new phase of social action. A perceptible improvement may be all that can be achieved by community action in one generation, but this will have a cumulative effect over the generations. Individuals are most susceptible to emotional influences in their early, formative years, and special attention should be paid to this fact when planning community measures. Thus the psychiatric service for children has a duty to make its findings on the emotional life of the child known to those agencies able to effect improvements in community living.

To conclude, the concept of the salutiferous (health-promoting) community is based on the idea that the whole emotional stratum of society should promote healthy emotional living. Thus, following an examination of the field of forces, a re-patterning of the forces takes place, which will encourage optimum conditions for emotional health. The programme calls for an examination of every aspect of social functioning, its standards, roles, institutions, organisation and aims. Every one of its multitudinous facets should be examined to assess its value in promoting emotional health. Those which are conducive to health should be retained; those that are antagonistic to health should be changed. The concentration is not on a sick person, the patient, but on the emotional self-improvement of the whole society. Over the generations, increasing self-improvement will result in a salutiferous society that supplies optimum conditions for emotional health in itself and its elements – culture, community, neighbourhood, family and individual.

Towards a Salutiferous Society

It is outside the scope of a book devoted to principles, to explore every avenue of social functioning. Thousands of instances from hundreds of areas would be necessary to approach a complete account. A few areas, and a few elements within them, will be taken for the purposes of illustration.

Values

Much harm comes to people from a common tendency in society to be critical of others to the point that they feel worthless, culpable and guilty. Some social institutions, for instance some religious movements, mistakenly regard this as a pathway to salvation. Underlying this widespread failing is a feeling of inferiority – others are blamed, cut down to size, so that the critics can feel superior. The widespread employment of this mechanism leads to immense unhappiness. Its removal would be a positive step towards happiness. It is clearly insufficient to expect that awareness alone will alter this practice. But it is a first step. The underlying inferiority also needs management.

Again, force and coercion, despite centuries of historical lessons pointing to the value of the reverse, are employed as instruments of social policy on an international, national and local level. “Force from force will ever flow”, in the words of Shelley, is a truth. Force evokes insecurity, inferiority, bitterness, hostility and a determination to react, if possible, with greater severity. Even if there appears no alternative to force, an avowal to use as little as is necessary to accomplish the task would be a valuable contribution. Just as force is a step backwards in interview psychotherapy, so it is in social action.

Competition has the virtue of encouraging creativity, effort and achievement. But it must be balanced by the right motives and be aimed at the common good. There is an optimum degree of competition which, if exceeded, becomes destructive to others and the individual, family or community. In education, children are frequently encouraged to be in severe academic competition with one another. Some obtain an excessive idea of their prowess. Some lose hope forever. At the same time an attitude of selfishness is inculcated which makes for sharp antagonism to others in many walks of life at a later date and fosters a disinclination to co-operate. An excess of the competitive spirit is destructive.

Legislation

Laws are ultimately created by the regulators of society, leaders, or by public opinion, to put into practice what is thought to be right for the common good. But some of the precepts on which legislation is based are themselves harmful. Whether or not the examples given below are correct is immaterial. The lesson to be drawn from them is that legislation should be evaluated for its emotional effects on society.

Divorce is sometimes regarded as an attack on the family and thus it is made difficult. It is thought that excessive divorce could kill the family. Yet a high divorce rate does not mean fewer families. Men and women are strongly attracted to each other and, following divorce, often come together in new unions. Should these new unions be satisfactory, they will not terminate, but will produce well-adjusted epitomes who will go forth and found stable succeeding families. We should endeavour to steer the divorced partners towards healthier unions. Again, it is supposed that highly incompatible partners should stay together “for the sake of the children”. But this practice is an attack on the family. It must create such a climate of disharmony that it produces disturbed children, who will in time found unstable succeeding families with a tendency to break up.

There has been much discussion in recent years on the advantages or otherwise of extending the control of childbirth into the first three months of pregnancy by allowing termination of pregnancy on the request of the mother. Some of the discussion (2) has turned around the philosophical issue of when the foetus can be regarded as a human entity; religious and legal bodies can hold vividly differing viewpoints, from the opinion that conception is the moment when life starts, to the opinion than an intrauterine age of 36 weeks indicates viability and independent existence. Even the Roman Catholic Church, in its long history, has found this decision of great complexity and, in the mid-19th century, changed its definition to its present attitude. But to the woman such discussions are irrelevant. To her the moment of psychological acceptance that she has a child is the crucial moment. Some develop an image based on willing acceptance at conception, to most it comes with “quickening” at about the 16th week, to others at birth – and for some acceptance is never achieved. The latter do not wish to nourish and produce an unwanted entity. Nor is it desirable to society that they should do so. Unwanted children are at risk emotionally. Thus it could be argued that to extend birth control into the first three months of pregnancy is highly desirable in that the mother has a last chance of preventing the birth of an unwanted child. The control of conception is now, but only now, universally regarded as desirable. Indeed the controversy over termination has suddenly underlined the value of birth control. But those who now oppose termination previously opposed the use of the “pill” and, before that, of contraception in general. This faces us with another subject for close study in a salutiferous society: What determines rigidity of attitudes? Those rigid in one direction are invariably so in another.

The subject of divorce leads to a consideration of another aspect of legislation. This is the tendency in law in many countries to give preferential consideration to the mother. The unique value of parenting by mother has been emphasised as an element in the extraordinary doctrine of psychoanalysis. In divorce proceedings in some, but not all, countries custody of the child is invariably given to the mother. Often this is correct. But each situation should be carefully evaluated and, in some circumstances, the child, and hence his succeeding family, would benefit from custody by his more loving father.

Authority

A society requires control and regulation. The regulation should arise as a willing acceptance by people that its laws are apposite and in the public interest. A basis of public support makes law enforcement much easier. Nevertheless, a machinery is necessary for law enforcement and this is usually placed in the hands of the police. The police can be regarded as friends and allies, but all too often they are regarded as a threat and as enemies. Thus there can be hostility between the public and its servants. The attitude of the police in these circumstances is crucial. Unnecessary force and belligerence lead to hostility and rear in return. Guns are met by guns. The greater the public hostility, the more insecure the police and the harsher their actions in self defence. From this confrontation come insecurity, fear and damage to a large number of people – no less to the police. Yet the right partnership can easily be developed. And it can start in childhood. By incidental help over small matters, children can grow up firmly convinced of the value of the police as friends. This can be enhanced by the police being actively involved in positive welfare programmes.

Societies need a machinery for massive collective action, they need a government. The control of this machine means wielding massive power. The machinery should be so constructed that its power is always at the behest of the people, or delegated to those under the public’s control. Those who wish for personal power naturally regard governmental machinery as a ready access to power. The misuse of power can deploy the whole of national organisation into a pattern of stress for its people. Probably no country has yet achieved an ideal prescription for the control of the collective national power.

The control of power can be the subject of early experience. Most children attend an institution, the school, where power has to be exercised. A number of people have rights - parents, head teachers, teachers and pupils. The school is far more than just a platform for the acquisition of knowledge. It is a slice of life. Thus, the way in which power, leadership, group relations, regulation, beliefs and logic are dealt with makes an indelible impression on children. The functioning of our schools and their advantageous or disadvantageous contribution to a salutiferous society is worthy of study.

Organisation

Some methods of organisation lead themselves to personal satisfaction, others to inferiority, disillusionment and the misuse of power. The inflexible use of the pyramidal structure is such a method. Essential in some situations, it is destructive in others. The pyramid consists of workers at the periphery with a hierarchy of power, usually termed “administration”, above. This is highly damaging in any situation in which the focal point is at the periphery and where the aim of the organisation is to give maximum service at the periphery. This is especially true of the helping professions. In them, there should be satisfaction in personal communication and the best people should be deployed. However, the best people, whether or not they have administrative gifts, are pulled away from the periphery up the pyramid by higher rewards and a refusal to be supervised by those less adequate than themselves. However, it is possible to create just as effective a system by a horizontal organisation, ie rewards and power going equally to all. Those with administrative flair are encouraged to organise, but with no greater rewards, and no more prestige or status, than their colleagues. The old guild system was very effective. An apprentice, or a trainee, learnt the craft and aimed to be a master craftsman; the journeyman was awaiting a master post or falling short of the necessary skill; the master had equality with all other masters.

Mention has already been made of the deployment of the invaluable, emotionally healthy section of society. Emotionally, the healthy are the salt of the earth. They have an invaluable asset, the capacity to communicate health to others. As a part of the programme of vector therapy, they must be deployed to act as a curative force for the psychonotics. In a salutiferous society, they must be deployed at key points – nurseries, homes, schools, the helping professions; they promote health and thus raise its standard.

Groups of people have an optimum size and structure for the most effective functioning. This applies not only to small groups, but also to estates and townships. It has been shown, for instance, that to create a township of young people leads in time to heavy demands for child care, which must be supplied, and ultimately leads to an aging population that can receive no support from the young.

Practices

People are more important than parents. More important for a child than right care from a parent is right care from somebody. The right care does not necessarily depend on the person supplying it being a “parent”. Yet the assumption that only parents can give the right care denies children help from many ready sources.

Again, some people, due to happy childhood experiences, have great capacity as parents. But some have none, others very little. Yet once designated as parents, persons have heaped on them complete and continuous responsibility for supplying loving care, and utter condemnation for failing in their responsibility if they are unsuccessful. We should be realistic and accept the varying capacities for parenting. Once this is accepted without blame, it becomes possible for parents lacking capacity to share responsibility with others without a feeling of failure or guilt. This in turn would make much easier the task of the helping professions and allow for the fortunate public with great parenting capacity to come helpfully forward without a feeling of competitiveness with the natural parent.

Knowledge is slowly being gained about the factors that control selection of complementary marriage partners. This can lead to a much higher prevalence of happy marriages. Basically, the more balanced people are, the greater the choice. Again, families should have a hand in selection. Happy family members choose those that conform to their families. Thus family selection in the old days was often successful. A formal test should be a deep and lengthy pre-marriage experience. Formal engagement should be replaced by trail marriage.

For a child to love a brother, sister, mother, aunt, nanny, teacher of playmate is acceptable. It is felt that a number of loving relationships are a virtue and an asset. Yet the same child, once grown up and married, must deny close loving to others outside the family circle. This is an artificial constraint, often not accepted in practice, but a widely held delusion. Again, it is supposed that the future of the family is protected by hostility, jealousy and deceit. Once families are secure, they will be able to add to their own strength and security by a pattern of loving, interlocking relationships.

Teaching

Teaching conveys facts; it does not change attitudes. Many essential functions in life are easily carried out; but there may still be a failure to do this because of underlying emotional attitudes. Mental defectives can manage intercourse; a university professor, because of attitudes that inhibit him, may be unable to do so. Educating him about the procedures of intercourse, giving him data he probably already possesses, does not overcome his emotional block. Thus there is a limit to what can be achieved by education in health matters. But where there is ignorance, education can overcome it, and it can extend the range of those people already adjusted enough to be able to make use of further data. Education is most effective with well-adjusted people, those who are already the best performers. It is less effective with the emotionally ill, those in most need of assistance.

To convey right information is a small but valuable part of a salutiferous society; many countries devise schemes for teaching mental hygiene. Slowly, knowledge is garnered about some of the nodal points in the life experience of a family – birth, sexual practices, preparation for marriage, childbirth, preparation for death, bereavement. But, notoriously, experts can be wrong. There is no greater fool than an expert fool. Because of emotional biases extraordinary errors can be made – for example, preoccupation with the breast feeding experience, instead of the infant’s whole waking experience; an almost total absence of interest in fathering; unchecked hypotheses about the child’s sexual life; separation being accepted as synonymous with deprivation, and the “natural home is better than any other home” philosophy; the mother-child relationship overvalued and the father-child relationship undervalued. False propaganda does harm. Much of the propaganda handed out during “mental health days” is ill-conceived. Little attention is paid to the meanings conveyed to the public. For example, the impression is often given that the mentally sick are peculiar and extraordinary. While this may attract some monetary help to these unfortunates, it also perpetuates the fear of mental illness. The terms “insanity” and “emotional disorder” are not clearly differentiated or understood by the public. Furthermore, the confusion causes the emotionally ill to be reluctant to seek help lest they be classed with such peculiar and extraordinary patients. Sometimes the emotional needs of the propagandists militate against a healthy approach.

REFERENCES

    1. HOWELLS, J.G. (1963). Family Psychiatry. Edinburgh : Oliver & Boyd.
    2. HOWELLS, J.G. (1972).  Termination of Pregnancy. In: Howells, J.G. (ed.) Modern Perspectives in Psycho-Obstetrics. Edinburgh: Oliver & Boyd; New York : Brunner/Mazel.

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